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Questions 163

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Question 1 of 5

The nurse in the outpatient clinic is caring for a client with heart failure who reports increased ankle swelling and a 3-lb (1.4-kg) weight gain over the past 2 days. The nurse reviews the client's current medications and anticipates the need for an increase in the dosage of which of the following medications?

Correct Answer: A

Rationale: A 3-lb weight gain and ankle swelling in heart failure indicate fluid retention, requiring an increased dose of a diuretic like bumetanide . Candesartan , carvedilol , and isosorbide manage other aspects but do not directly address acute fluid overload.

Question 2 of 5

The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first?

Correct Answer: D

Rationale: A fever of 100.9 F post-arteriovenous graft suggests possible infection, requiring immediate assessment. Cramping and minor bleeding are expected post-polypectomy, urinary hesitancy is common post-hernia repair, and straining is less urgent.

Question 3 of 5

The nurse is assessing a 1-month-old infant with atrial septal defect. Which of the following findings would be consistent with the condition?

Correct Answer: C

Rationale: An atrial septal defect often presents with a heart murmur due to abnormal blood flow. Cyanosis is rare unless severe, muffled tones are not typical, and weak femoral pulses suggest coarctation of the aorta.

Question 4 of 5

Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention?

Correct Answer: A

Rationale: The child who is confused and irritable with missing glyburide pills suggests a potential hypoglycemic emergency due to sulfonylurea overdose, which requires immediate intervention to prevent severe complications like seizures or coma.

Question 5 of 5

The nurse is caring for a client with spontaneous rupture of membranes. The nurse notes a loop of umbilical cord protruding from the vagina. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: Umbilical cord prolapse is an emergency requiring the knee-chest position to relieve cord compression. Suprapubic pressure and McRoberts are for shoulder dystocia, and Leopold maneuvers are for fetal positioning assessment.

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